MEDICARE: LINH TRUONG BRADBERRY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN19050	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN19050	OTHER	FL	STATE DENTAL LICENSE

General Provider Information

NPI Number	:	1841505757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINH TRUONG BRADBERRY DMD

Provider Business Mailing Address
First Line	:	5911 TIMUQUANA RD STE 202
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-8174
Country	:	US
Telephone Number	:	904-993-6088
Fax Number	:	904-993-6088

Provider Business Practice Location Address
First Line	:	10915 BAYMEADOWS RD STE 106
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9131
Country	:	US
Telephone Number	:	904-619-6478
Fax Number	:	904-580-4262

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2010
Last Update Date	:	06/03/2022

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